Summary of Benefits Full PPO Split Deductible 35-1000 80/60 Group Plan PPO Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California benefit Plan. It is only a summary and it is part of the contract for health care coverage, called the Evidence of Coverage (EOC). 1 Please read both documents carefully for details. Provider Network: Full PPO Network This benefit Plan uses a specific network of Health Care Providers, called the Full PPO provider network. Providers in this network are called Providers. You pay less for Covered Services when you use a Provider than when you use a Non- Provider. You can find Providers in this network at blueshieldca.com. Calendar Year Deductibles (CYD) 2 A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for Covered Services under the benefit Plan. Blue Shield pays for some Covered Services before the Calendar Year Deductible is met, as noted in the Benefits chart below. A44633 (1/19) 1 Calendar Year medical Deductible Individual coverage $1,000 $2,000 Family coverage Calendar Year Out-of-Pocket Maximum 5 An Out-of-Pocket Maximum is the most a Member will pay for Covered Services each Calendar Year. Any exceptions are listed in the Notes section at the end of this Summary of Benefits. Individual coverage $5,500 $10,000 Family coverage $5,500: individual $11,000: Family ny combination of 3 or Non- 4 Providers $10,000: individual $20,000: Family $1,000: individual $2,000: Family Non- $2,000: individual $4,000: Family No Lifetime Benefit Maximum Under this benefit Plan there is no dollar limit on the total amount Blue Shield will pay for Covered Services in a Member s lifetime. Blue Shield of California is an independent member of the Blue Shield Association
Benefits 6 Non- Preventive Health Services 7 $0 Not covered California Prenatal Screening Program $0 $0 Physician services Primary care office visit $35/visit 40% Specialist care office visit $35/visit 40% Physician home visit $35/visit 40% Physician or surgeon services in an Outpatient Facility 20% 40% Physician or surgeon services in an inpatient facility 20% 40% Other professional services Other practitioner office visit $35/visit 40% Includes nurse practitioners, physician assistants, and therapists. Acupuncture services $25/visit 40% Up to 20 visits per Member, per Calendar Year. Chiropractic services $25/visit 40% Up to 20 visits per Member, per Calendar Year. Teladoc consultation $5/consult Not covered Family planning Counseling, consulting, and education $0 Not covered Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. $0 Not covered Tubal ligation $0 Not covered Vasectomy 20% Not covered Infertility services Not covered Not covered Podiatric services $35/visit 40% Pregnancy and maternity care 7 Physician office visits: prenatal and postnatal 20% 40% Physician services for pregnancy termination 20% 40% 2
Benefits 6 Non- Emergency services Emergency room services $150/visit plus 20% $150/visit plus 20% If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services 20% 20% Urgent care center services $35/visit 40% Ambulance services 20% 20% This payment is for emergency or authorized transport. Outpatient Facility services Ambulatory Surgery Center 10% Outpatient department of a Hospital: surgery 25% Outpatient department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies Inpatient facility services 20% Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay. Special transplant facility inpatient services $100/admission plus 20% $100/admission plus 20% $600/day Not covered Physician inpatient services 20% Not covered 3
Benefits 6 Non- Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of nondesignated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient Facility services and Outpatient Physician services payments apply. Inpatient facility services $100/admission plus 20% Not covered Outpatient Facility services 25% Not covered Physician services 20% Not covered Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for Covered Services that are diagnostic, non-preventive Health Services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test. Laboratory center $35/visit 40% Outpatient department of a Hospital $60/visit X-ray and imaging services Includes diagnostic mammography. Outpatient radiology center $35/visit 40% Outpatient department of a Hospital $60/visit 4
Benefits 6 Non- Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG. Office location $35/visit 40% Outpatient department of a Hospital $60/visit Radiological and nuclear imaging services Outpatient radiology center 20% 40% Outpatient department of a Hospital 20% Rehabilitative and Habilitative Services Includes Physical Therapy, Occupational Therapy, Respiratory Therapy, and Speech Therapy services. Office location $35/visit 40% Outpatient department of a Hospital $35/visit Durable medical equipment (DME) DME 20% 40% Breast pump $0 Not covered Orthotic equipment and devices 20% 40% Prosthetic equipment and devices 20% 40% 5
Benefits 6 Non- Home health services Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period, except hemophilia and home infusion nursing visits. Home health agency services 20% Not covered Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist. Home visits by an infusion nurse 20% Not covered Home health medical supplies 20% Not covered Home infusion agency services 20% Not covered Hemophilia home infusion services 20% Not covered Includes blood factor products. Skilled Nursing Facility (SNF) services Up to 100 days per Member, per Benefit Period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF 20% 20% Hospital-based SNF 20% $600/day Hospice program services $0 Not covered Includes pre-hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. Other services and supplies Diabetes care services Devices, equipment, and supplies 20% 40% Self-management training $35/visit 40% Dialysis services 20% 6
Benefits 6 Non- PKU product formulas and Special Food Products 20% 20% Allergy serum 20% 40% Mental Health and Substance Use Disorder Benefits Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Services Administrator (MHSA). MHSA MHSA Non- Outpatient services Office visit, including Physician office visit $35/visit 40% Other outpatient services, including intensive outpatient care, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non-institutional facility setting, and office-based opioid treatment Partial Hospitalization Program 20% 20% 40% Psychological Testing 20% 40% Inpatient services Physician inpatient services $0 40% Hospital services Residential Care $100/admission plus 20% $100/admission plus 20% $600/day $600/day 7
Prior Authorization The following are some frequently-utilized Benefits that require prior authorization: Radiological and nuclear imaging services Mental health services, except outpatient office visits Inpatient facility services Hospice program services Home health services from Non- Providers Please review the Evidence of Coverage for more about Benefits that require prior authorization. Notes 1 Evidence of Coverage (EOC): The Evidence of Coverage (EOC) describes the Benefits, limitations, and exclusions that apply to coverage under this benefit Plan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time. Defined terms are in the EOC. Refer to the EOC for an explanation of the terms used in this Summary of Benefits. 2 Calendar Year Deductible (CYD): Calendar Year Deductible explained. A Deductible is the amount you pay each Calendar Year before Blue Shield pays for Covered Services under the benefit Plan. If this benefit Plan has any Calendar Year Deductible(s), Covered Services subject to that Deductible are identified with a check mark () in the Benefits chart above. Covered Services not subject to the Calendar Year medical Deductible. Some Covered Services received from Providers are paid by Blue Shield before you meet any Calendar Year medical Deductible. These Covered Services do not have a check mark () next to them in the CYD column in the Benefits chart above. This benefit plan has separate Deductibles for: Provider Deductible and Non- Provider Deductible Family coverage has an individual Deductible within the Family Deductible. This means that the Deductible will be met for an individual with Family coverage who meets the individual Deductible prior to the Family meeting the Family Deductible within a Calendar Year. 3 Using Providers: Providers have a contract to provide health care services to Members. When you receive Covered Services from a Provider, you are only responsible for the Copayment or Coinsurance, once any Calendar Year Deductible has been met. for services from Other Providers. You will pay the Copayment or Coinsurance applicable to Providers for Covered Services received from Other Providers. However, Other Providers do not have a contract to provide health care services to Members and so are not Providers. Therefore, you will also pay all above the Allowable Amount. This out-of-pocket expense can be significant. 4 Using Non- Providers: Non- Providers do not have a contract to provide health care services to Members. When you receive Covered Services from a Non- Provider, you are responsible for both: the Copayment or Coinsurance (once any Calendar Year Deductible has been met), and 8
Notes any above the Allowable Amount (which can be significant). Allowable Amount is defined in the EOC. In addition: Any Coinsurance is determined from the Allowable Amount. Any above the Allowable Amount are not covered, do not count towards the Out-of-Pocket Maximum, and are your responsibility for payment to the provider. This out-of-pocket expense can be significant. Some Benefits from Non- Providers have the Allowable Amount listed in the Benefits chart as a specific dollar ($) amount. You are responsible for any above the Allowable Amount, whether or not an amount is listed in the Benefits chart. 5 Calendar Year Out-of-Pocket Maximum (OOPM): after you reach the Calendar Year OOPM. You will continue to pay all above a Benefit maximum. Essential health benefits count towards the OOPM. Any Deductibles count towards the OOPM. Any amounts you pay that count towards the medical Calendar Year Deductible also count towards the Calendar Year Out-of-Pocket Maximum. This benefit Plan has a Provider OOPM as well as a combined Provider and Non- Provider OOPM. This means that any amounts you pay towards your Provider OOPM also count towards your combined and Non- Provider OOPM. Family coverage has an individual OOPM within the Family OOPM. This means that the OOPM will be met for an individual with Family coverage who meets the individual OOPM prior to the Family meeting the Family OOPM within a Calendar Year. 6 Separate Member Payments When Multiple Covered Services are Received: Each time you receive multiple Covered Services, you might have separate payments (Copayment or Coinsurance) for each service. When this happens, you may be responsible for multiple Copayments or Coinsurance. For example, you may owe an office visit Copayment in addition to an allergy serum Copayment when you visit the doctor for an allergy shot. 7 Preventive Health Services: If you only receive Preventive Health Services during a Physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the Physician office visit, you may have a Copayment or Coinsurance for the visit. Benefit Plans may be modified to ensure compliance with State and Federal requirements. 9
Blue Shield of California Notice Informing Individuals about Nondiscrimination and Accessibility Requirements Discrimination is against the law Blue Shield of California complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. Blue Shield of California does not exclude people or treat them differently because of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. Blue Shield of California: Provides aids and services at no cost to people with disabilities to communicate effectively with us such as: - Qualified sign language interpreters - Written information in other formats (including large print, audio, accessible electronic formats, and other formats) Provides language services at no cost to people whose primary language is not English such as: - Qualified interpreters - Information written in other languages If you need these services, contact the Blue Shield of California Civil Rights Coordinator. If you believe that Blue Shield of California has failed to provide these services or discriminated in another way on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability, you can file a grievance with: Blue Shield of California Civil Rights Coordinator P.O. Box 629007 El Dorado Hills, CA 95762-9007 Phone: (844) 831-4133 (TTY: 711) Fax: (844) 696-6070 Email: BlueShieldCivilRightsCoordinator@blueshieldca.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC 20201 (800) 368-1019; TTY: (800) 537-7697 Blue Shield of California is an independent member of the Blue Shield Association A49726-DMHC (1/18) Complaint forms are available at www.hhs.gov/ocr/office/file/index.html. Blue Shield of California 50 Beale Street, San Francisco, CA 94105
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